Appointment Information
Select Provider
Kamyar Assil, MD
Kimberley K. Caputo, MD
Daniel K. Davis, MD
Kevin M. Deitel, MD, FRCS(C)
Michael J. Fealy, MD
Mark J. Ghilarducci, MD
Joshua S. Gluck, MD
Gregg P. Hartman, MD
Jason K. Hofer, MD
Thomas J. Horn, MD
Andre M. Ishak, MD
Ali R. Motamedi, MD
F. Ray Nickel, MD
Alen A. Nourian, MD
Robert M. O'Hollaren, MD
Sohrab Pahlavan, MD
Timothy J. Rearick, MD
Kentaro P. Suzuki, MD
Joseph P. Turk, MD
Craig A. Zeman, MD
Select Location
Camarillo
Oxnard
Simi Valley
Thousand Oaks
Ventura
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Contact Information
Jr, Sr, etc.
Jr.
Sr.
II
III
IV
V
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Contact Information
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Contact Information
OK to leave message:
Home Phone
Cell Phone
Work Phone
Do you prefer to receive reminder messages in the:
Morning
Afternoon
Evening
Do you prefer:
Voice Message
Text Message
Special Arrangement
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Demographics
Race:
Hispanic
White
Asian
African American
Native Hawaiian
Prefer Not to Answer
Other
Ethnicity:
Hispanic
White
Prefer Not to Answer
Other
Preferred Language:
English
Spanish
Chinese
Japanese
Other
Do you need an interpreter present during your examination?
Yes
No
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Doctor Referral
Did another doctor send you to this office for evaluation?
Yes
No
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Appointment Information
Problem involves the:
Shoulder
Right
Left
Bilateral
Elbow
Right
Left
Bilateral
Forearm
Right
Left
Bilateral
Wrist
Right
Left
Bilateral
Hand
Right
Left
Bilateral
Finger
Right
Left
Bilateral
Neck
Right
Left
Bilateral
Hip
Right
Left
Bilateral
Thigh
Right
Left
Bilateral
Knee
Right
Left
Bilateral
Leg
Right
Left
Bilateral
Ankle
Right
Left
Bilateral
Foot
Right
Left
Bilateral
Toe
Right
Left
Bilateral
Back
Right
Left
Bilateral
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Appointment Information
Was there an injury which you believe directly resulted in your symptoms?
Yes
No
Is the injury work related?
Yes
No
Is this a result of a motor vehicle accident?
Yes
No
Please give an approximate time when the symptoms began:
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Appointment Information
Have you sought medical treatment for this problem prior to this visit?
Yes
No
Where did you receive the medical treatment?
Hospital
Urgent Care
Physician's Office
Other
What treatment was given?
Braces/Splint
Crutches
Cast
Therapy
Chiropractic
What medication was given?
Narcotic
Anti-inflammatory
Muscle relaxers
Corticosteroids
Injection
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Appointment Information
For the problem you are being seen for today, have you had any of the following:
X-rays
CT/CAT
MRI
Nerve Test
Arthrogram
Myelogram
Discogram
Have you had surgery on this body part?
Yes
No
Have you had symptoms or an injury to this area before?
Yes
No
Please Describe
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Appointment Information
Are you experiencing pain at the present time?
Yes
No
Pain is described as:
Improved
Worse
The Same
Moderate
Severe
Sharp
Dull
Burning
Aching
Constant
Present only at time or with certain activities
Does the pain radiate?
Yes
No
Where on the body?
Is there:
Swelling
Numbness
Tingling
Weakness
A Mass
Deformity
What makes your problem worse?
What makes your problem better?
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Medical History
Osteoporosis
Cancer
High Blood Pressure
Heart Disease
Paralysis
Arthritis
Other
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Social History
Tobacco Use: Are you a...
Current Smoker
Former Smoker
Never Smoked
How long have you smoked?
Less than 1 year
1-10 years
10+ years
How many packs per day?
Less than 1 pack
1-2 packs
3+ packs
When did you quit smoking?
Do you drink alcohol regularly?
Yes
No
How many drinks per week?
Less than 4 drinks
5-9 drinks
10+ drinks
Have you used or do you use other drugs?
Yes
No
What drugs do you use?
Street Drugs
Steroids
Other
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Social History
Level of education completed:
Elementary
High School
College
Graduate
Marriage Status:
Single
Married
Divorced
Widowed
Occupation:
Gender:
Male
Female
If you are a female between the age of 10-65, are you pregnant?
Yes
No
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Family History
Mother
Alive
Deceased
Diabetes
High Blood Pressure
Heart Disease
Stroke
Unknown
Father
Alive
Deceased
Diabetes
High Blood Pressure
Heart Disease
Stroke
Unknown
Siblings
Alive
Deceased
Diabetes
High Blood Pressure
Heart Disease
Stroke
Unknown
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Review of Systems
Are you experiencing any of these issues now?
General
Fever
Night Sweats/Chills
Night Pain
Weight Loss
Eyes
Cataracts
Blindness
Double Vision
Head Eyes Ears Nose Throat
Cough
Sinus Problems
Hearing Loss
Dentures
Loose Tooth
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Review of Systems
Are you experiencing any of these issues now?
Heart
Chest Pain
Irregular Heart Beats
High Blood Pressure
Lungs
Wheezing
Shortness of Breath
Pain with Breathing
Sputum Production
Abdominal
Heart Burn
Difficult Swallowing
Nausea & Vomiting
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Review of Systems
Are you experiencing any of these issues now?
Urinary
Incontinence
Kidney Stones
Muscularskeletal
Joint Swelling
Muscle Cramps
Stiffness
Skin & Breast
Rash
Changes in Moles
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Review of Systems
Are you experiencing any of these issues now?
Neurologic
Seizures
Loss of Consciousness
Balance Problems
Headaches
Psychiatric
Depression
Hyperactivity
Difficult Sleeping
Metabolism
Weight Gain
High Blood Sugar
Blood
Anemia
Prolonged Bleeding
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Review of Systems
Allergies
Are you Allergic to any medications?
Yes
No
Are you allergic to food or environmental substances?
Yes
No
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Review of Systems
Medications
Are you currently taking any medications?
Yes
No
Hospitalizations
Have you had any hospitalizations?
Yes
No
Surgeries
Have you had any Surgeries?
Yes
No
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Insurer Info
Subscriber Info
Subscriber Relationship to Patient
Self
Spouse
Partner
Parent
Other
Insurance Info
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